- Email: [email protected]
Unprocessed Bran and Intermittent Thiazide Therapy in Prevention of Recurrent Urinary Calcium Stones
RENAL CALCULI
and ultrasonography. The procedure was performed in a single stage under general anaesthesia, adopting the method and instruments used for one stage percutaneous nephrolithotomy. A Foley catheter was left in the gallbladder and the system checked with contrast at 10 days to ensure free drainage and exclude residual calculi. Seven out of eight patients had a successful percutaneous cholecystolithotomy. An adequate track could not be secured in one man; he had an uneventful cholecystectomy under the same anaesthetic. Follow up at three months of the seven patients showed no calculi and no complications. Percutaneous cholecystolithotomy may prove complementary to extracorporeal shockwave lithotripsy in patients in whom there is difficulty focusing the shock waves on the gallbladder or who have had incomplete disintegration of stones. Editorial Comment: With the impending implementation of gallstone lithotripsy, it is extremely desirable to have a safety net technique of percutaneous drainage and stone retrieval to avert severe obstruction or cholangitis. The authors use direct percutaneous puncture of the gallbladder under ultrasonic guidance to obtain access to the gallbladder. Many of the techniques used are similar to those performed in percutaneous nephrolithotomy. The principal technical problem encountered was the inability to dilate the tract into the gallbladder. The fundus of the gallbladder is much more mobile than a kidney and the authors believe that a transperitoneal approach under ultrasound control with balloon dilation is imperative. The gallbladder wall invaginates with dilators greater than 16 Ch. and, therefore, balloon dilation was required in all instances. With our experience in shock wave lithotripsy and percutaneous surgery, urologists have much to offer general surgeons in the field of percutaneous gallbladder surgery. I believe that the 2 specialties should work in conjunction in this area of medicine. Mani Menon, M.D. Unprocessed Bran and Intermittent Thiazide Therapy in Prevention of Recurrent Urinary Calcium Stones
M. ALA-0PAS, I. ELOMAA, L. PORKKA AND 0. ALFTHAN, Urological Unit, Second Department of Surgery, Third Department of Internal Medicine and Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland Scand. J. Urol. Nephrol., 21: 311-314, 1987 Both urinary calcium excretion and renal stone episodes are increased during the summer in Finland. Since thiazide and unprocessed bran are known to decrease urinary calcium excretion, we treated 73 patients with recurrent urinary stone formation by giving them unprocessed bran and intermittent thiazide. Of the patients, 32 had absorptive hypercalciuria and 41 had normal urinary calcium values. All patients were on a low-calcium and low-oxalate diet and took 40 g bran daily. Fourteen of the hypercalciuric and 14 of the normocalciuric patients were randomly allocated to use hydrochlorothiazide 50 mg. b.i.d. from May to September. Reduction of stone formation was seen in all groups. The combination of thiazide + bran was superior to the bran on its own in inhibition of stone formation. Only 3/11 (27%) stones passed through during the summer in the thiazide + bran group as compared with the 11/17 (65%) in the bran group.
467
Editorial Comment: In this Scandinavian study 73 patients with recurrent calcium stones were treated with a low calcium, low oxalate, high fluid intake diet and unprocessed bran for 24 months. Hydrochlorothiazide was added randomly to 14 normocalciuric and 14 hypercalciuric patients for 5 months. A 70 to 85 per cent decrease in urinary stone formation was seen in all groups. A decrease in urinary calcium excretion was present in all groups but was more pronounced in patients on hydrochlorothiazide. In contrast, despite being on a low oxalate diet urinary oxalate excretion actually increased in most groups. This is a controlled prospective, somewhat randomized study on the effect of thiazides on nephrolithiasis. In a group of recurrent stone patients in whom calculi developed every 18 to 24 months before therapy, stone formation rates were decreased to a projected rate of 1 every 4 to 6 years. Furthermore, three-fourths of the patients were free of stone during 2 years of followup. The study shows that fluid intake, dietary calcium and oxalate restriction, and unprocessed bran form adequate treatment for normocalciuric patients. For patients with hypercalciuria the addition of thiazides seems helpful, even though the patients had absorptive rather than renal hypercalciuria. Mani Menon, M.D. Pulsed Dye Laser for Treatment of Ureteral Calculi
J. W. SEGURA, Department of Urology, Mayo Clinic, Rochester, Minnesota Urol. Clin. N. Amer., 15: 257-262, 1988 The pulsed-dye laser is safe and effective. The commercially available machine appears smoother to operate and far less cumbersome than its prototype. When access to the stone is through small (8.5F) rigid ureteroscopes the laser outperforms ultrasound and electrohydraulic lithotrites. With larger ureteroscopes the laser has no particular advantage over ultrasound. When small, flexible steerable ureteroscopes are available, the laser will come into its own. Editorial Comment: This is a thoughtful review of the use of the pulsed dye laser for the treatment of ureteral calculi. The main advantage of this laser is that it can be used through smaller and flexible steerable endoscopes. This form of treatment ultimately may be more useful for percutaneous gallstone lithotripsy than renal lithotripsy. Mani Menon, M.D. Complications of Extracorporeal Shock-Wave Lithotripsy and Percutaneous Nephrolithotomy
R.
A. ROTH AND C. F. BECKMANN, Lahey Clinic Center for Stone Disease and Department of Diagnostic Radiology, Lahey Clinic Medical Center, Burlington, Massachusetts
Urol. Clin. N. Amer., 15: 155-166, 1988 The serious complications of ESWL associated with the Dornier HM-3 lithotripter are well known. It is incumbent on operators to recognize these problems and, when possible, to anticipate them and utilize a treatment plan that will minimize their occurrence. Appropriate use of percutaneous techniques, double J-stents, and ureteroscopy and aggressive use of anti-
and ultrasonography. The procedure was performed in a single stage under general anaesthesia, adopting the method and instruments used for one stage percutaneous nephrolithotomy. A Foley catheter was left in the gallbladder and the system checked with contrast at 10 days to ensure free drainage and exclude residual calculi. Seven out of eight patients had a successful percutaneous cholecystolithotomy. An adequate track could not be secured in one man; he had an uneventful cholecystectomy under the same anaesthetic. Follow up at three months of the seven patients showed no calculi and no complications. Percutaneous cholecystolithotomy may prove complementary to extracorporeal shockwave lithotripsy in patients in whom there is difficulty focusing the shock waves on the gallbladder or who have had incomplete disintegration of stones. Editorial Comment: With the impending implementation of gallstone lithotripsy, it is extremely desirable to have a safety net technique of percutaneous drainage and stone retrieval to avert severe obstruction or cholangitis. The authors use direct percutaneous puncture of the gallbladder under ultrasonic guidance to obtain access to the gallbladder. Many of the techniques used are similar to those performed in percutaneous nephrolithotomy. The principal technical problem encountered was the inability to dilate the tract into the gallbladder. The fundus of the gallbladder is much more mobile than a kidney and the authors believe that a transperitoneal approach under ultrasound control with balloon dilation is imperative. The gallbladder wall invaginates with dilators greater than 16 Ch. and, therefore, balloon dilation was required in all instances. With our experience in shock wave lithotripsy and percutaneous surgery, urologists have much to offer general surgeons in the field of percutaneous gallbladder surgery. I believe that the 2 specialties should work in conjunction in this area of medicine. Mani Menon, M.D. Unprocessed Bran and Intermittent Thiazide Therapy in Prevention of Recurrent Urinary Calcium Stones
M. ALA-0PAS, I. ELOMAA, L. PORKKA AND 0. ALFTHAN, Urological Unit, Second Department of Surgery, Third Department of Internal Medicine and Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland Scand. J. Urol. Nephrol., 21: 311-314, 1987 Both urinary calcium excretion and renal stone episodes are increased during the summer in Finland. Since thiazide and unprocessed bran are known to decrease urinary calcium excretion, we treated 73 patients with recurrent urinary stone formation by giving them unprocessed bran and intermittent thiazide. Of the patients, 32 had absorptive hypercalciuria and 41 had normal urinary calcium values. All patients were on a low-calcium and low-oxalate diet and took 40 g bran daily. Fourteen of the hypercalciuric and 14 of the normocalciuric patients were randomly allocated to use hydrochlorothiazide 50 mg. b.i.d. from May to September. Reduction of stone formation was seen in all groups. The combination of thiazide + bran was superior to the bran on its own in inhibition of stone formation. Only 3/11 (27%) stones passed through during the summer in the thiazide + bran group as compared with the 11/17 (65%) in the bran group.
467
Editorial Comment: In this Scandinavian study 73 patients with recurrent calcium stones were treated with a low calcium, low oxalate, high fluid intake diet and unprocessed bran for 24 months. Hydrochlorothiazide was added randomly to 14 normocalciuric and 14 hypercalciuric patients for 5 months. A 70 to 85 per cent decrease in urinary stone formation was seen in all groups. A decrease in urinary calcium excretion was present in all groups but was more pronounced in patients on hydrochlorothiazide. In contrast, despite being on a low oxalate diet urinary oxalate excretion actually increased in most groups. This is a controlled prospective, somewhat randomized study on the effect of thiazides on nephrolithiasis. In a group of recurrent stone patients in whom calculi developed every 18 to 24 months before therapy, stone formation rates were decreased to a projected rate of 1 every 4 to 6 years. Furthermore, three-fourths of the patients were free of stone during 2 years of followup. The study shows that fluid intake, dietary calcium and oxalate restriction, and unprocessed bran form adequate treatment for normocalciuric patients. For patients with hypercalciuria the addition of thiazides seems helpful, even though the patients had absorptive rather than renal hypercalciuria. Mani Menon, M.D. Pulsed Dye Laser for Treatment of Ureteral Calculi
J. W. SEGURA, Department of Urology, Mayo Clinic, Rochester, Minnesota Urol. Clin. N. Amer., 15: 257-262, 1988 The pulsed-dye laser is safe and effective. The commercially available machine appears smoother to operate and far less cumbersome than its prototype. When access to the stone is through small (8.5F) rigid ureteroscopes the laser outperforms ultrasound and electrohydraulic lithotrites. With larger ureteroscopes the laser has no particular advantage over ultrasound. When small, flexible steerable ureteroscopes are available, the laser will come into its own. Editorial Comment: This is a thoughtful review of the use of the pulsed dye laser for the treatment of ureteral calculi. The main advantage of this laser is that it can be used through smaller and flexible steerable endoscopes. This form of treatment ultimately may be more useful for percutaneous gallstone lithotripsy than renal lithotripsy. Mani Menon, M.D. Complications of Extracorporeal Shock-Wave Lithotripsy and Percutaneous Nephrolithotomy
R.
A. ROTH AND C. F. BECKMANN, Lahey Clinic Center for Stone Disease and Department of Diagnostic Radiology, Lahey Clinic Medical Center, Burlington, Massachusetts
Urol. Clin. N. Amer., 15: 155-166, 1988 The serious complications of ESWL associated with the Dornier HM-3 lithotripter are well known. It is incumbent on operators to recognize these problems and, when possible, to anticipate them and utilize a treatment plan that will minimize their occurrence. Appropriate use of percutaneous techniques, double J-stents, and ureteroscopy and aggressive use of anti-